How difficult is it to remove the entire gland?

[Zim]

Hello,

I had surgery in November and requested the entire gland be removed due to the physical discomfort it was causing. The surgeon assured me the entire gland had been removed and post-op my chest looked perfectly and completely flat, very clean work. Unfortunately the pain started up again a few months post-op and I now have gyno again. I spoke to my endocrinologist and she said obviously some of the gland was left in.
I would like to ask any surgeons - how difficult is it to remove the entire gland? I understand it's often not a simple "ball" of tissue, it can be quite stringy and hard to get the whole thing out.
I'll be going for revision surgery and this time would like to guarantee entire gland removal. I will probably consult with a gyne surgeon expert before going under the knife again.

[Dr. Elliot Jacobs]

First, you have to understand the anatomy of a chest with gynecomastia.  Breast tissue is mostly concentrated under the areolas and then it spreads out in all directions as fingers of gland intertwined with fingers of fat.

Gynecomastia surgery is meant to re-shape the chest to a more sculpted, masculine look -- it is not a cancer operation and total removal of all breast tissue is not required.  In fact, all normal-appearing men have some amount of breast tissue on their chest!  If a surgeon tried to remove every last vestige of breast tissue, your chest would surely be mutilated.

What you have to be aware of is that after surgery, one can develop scar tissue which may mimic recurrence of breast tissue -- and it may be tender or sensitive.  Only your surgeon would know how much, if any breast tissue, he left under your nipples.  He/she is the best person to speak to about your present situation.  Of course, you are always welcome to seek another opinion, preferably with an experienced gyne surgeon in your area.

Good luck!

Dr Jacobs

[Litlriki]

Dr. Jacobs has explained the anatomy clearly.  And the reason you would appear mutilated if the "entire gland" were removed is that the nipple would really have to be taken off completely (as in breast cancer surgery), since the tissue under it is "gland."  As a result, we all leave a little bit of tissue under the areola with this surgery.  Your surgeon will be the best one to ask how much tissue is still there. 

Rick Silverman

[Zim]

Thank you very much for the comments guys.
I've been educating myself some more on the anatomy of gyne. This paper has been helpful.

"[font="Times New Roman", stixgeneral, serif]In virtually all cases, a subcutaneous mastectomy was performed, leaving behind only 2 to 3 mm of glandular tissue under the skin"[/font][/i]


"[font="Times New Roman", stixgeneral, serif]In patients with low fat content, care was taken to remove all of the glandular tissue"[/font][/i]

Two seemingly contradictory statements, first stating 2-3mm of gland is left, the next stating "all" glandular tissue was removed. This echoes a lot of the confusing statements surrounding gyne surgery.
When my endocrinologist confirmed with ultrasound that I had glandular tissue regrowing (now 7 months post-surgery) she said "the surgeon didn't take all of the gland". But my surgeon says he took all of the gland. I assume he just means he took the bulk of it since as you say, you would have to take the entire nipple off otherwise. Directly post-op my chest was perfectly flat, clearly most of the gland had been taken. I had scar tissue build-up in the following weeks which dissipated. Around 2 months post-op the gyno pain started again and the glandular tissue has been growing since.
I would appreciate your advice on what my next step should be. I have a recurrence of extremely painful gynecomastia. I understand most cases of gyne are uncomfortable/mildly painful at worst. It appears to be idiopathic: my bloods are all normal and I have never/am not taking any medication that could cause this. I'm slim and healthy otherwise. I've tried all anti-estrogens for 6 months+ with no change. I've had surgery with gland removal. I would happily go for surgery again if I thought it would help, but I figure the tissue is just going to come back.

[Zim]

Thank you very much for the comments guys.
I've been educating myself some more on the anatomy of gyne. This paper has been helpful.

"In virtually all cases, a subcutaneous mastectomy was performed, leaving behind only 2 to 3 mm of glandular tissue under the skin"


"In patients with low fat content, care was taken to remove all of the glandular tissue"

Two seemingly contradictory statements, first stating 2-3mm of gland is left, the next stating "all" glandular tissue was removed. This echoes a lot of the confusing statements surrounding gyne surgery.
When my endocrinologist confirmed with ultrasound that I had glandular tissue regrowing (now 7 months post-surgery) she said "the surgeon didn't take all of the gland". But my surgeon says he took all of the gland. I assume he just means he took the bulk of it since as you say, you would have to take the entire nipple off otherwise. Directly post-op my chest was perfectly flat, clearly most of the gland had been taken. I had scar tissue build-up in the following weeks which dissipated. Around 2 months post-op the gyno pain started again and the glandular tissue has been growing since.
I would appreciate your advice on what my next step should be. I have a recurrence of extremely painful gynecomastia. I understand most cases of gyne are uncomfortable/mildly painful at worst. It appears to be idiopathic: my bloods are all normal and I have never/am not taking any medication that could cause this. I'm slim and healthy otherwise. I've tried all anti-estrogens for 6 months+ with no change. I've had surgery with gland removal. I would happily go for surgery again if I thought it would help, but I figure the tissue is just going to come back.

[DrPensler]

To remove "all of the gland" the surgeon needs to remove the nipple and areola. Total removal is done only for cancer excision. There is a small amount of glandular tissue which extends into the nipple itself and therefore as mention for a cancer excision to ensure complete removal of all  glandular tissue the nipple is excised. As you can well imagine this is disfiguring and secondary reconstruction of the nipple and areola is required and it just is never done for aesthetic reasons.